Patient with uncontrolled BP despite 3 antihypertensives (including a thiazide diuretic) at optimal doses. Action: confirm adherence, assess reversible causes, propose quadrupel therapy or refer to secondary care.
Hypertensive crisis (BP ≥ 180/110 with headache, visual disturbance, chest pain or dyspnoea) → refer immediately. Elevated K+ or renal deterioration after starting spironolactone → stop and reassess.
Confirm adherence (interview + pill count). Exclude pseudo-resistance: incorrect measurement technique, undeclared NSAID use, alcohol, or white-coat effect (ABPM).
Obstructive sleep apnoea, primary hyperaldosteronism, phaeochromocytoma, renal artery stenosis, Cushing syndrome. Seek medical guidance if suspected.
Keep ACEi/ARB at optimal dose + aldosterone antagonist (spironolactone 25mg) + thiazide diuretic + calcium channel blocker. Monitor K+ and renal function in 7–14 days.
If BP remains uncontrolled after maximal pharmacological optimisation: refer for difficult-to-control hypertension. Document all drugs tried and their doses.
The combination of ACEi + spironolactone + a K+-sparing diuretic increases the risk of hyperkalaemia. Check baseline K+ before starting. Do not use in patients with eGFR < 30 mL/min without specialist guidance.
DGS Guideline No. 001/2026 — Diagnostic and Therapeutic Approach to the Person with Hypertension
Official source